PROVIDENCE MEDICARE ADVANTAGE PLANS Plan Comparison Western Oregon and Clark County Washington H9047_2015PHP40_ACCEPTED

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1 PROVIDENCE MEDICARE ADVANTAGE PLANS 2015 Plan Comparison Western Oregon and Clark County Washington H9047_2015PHP40_ACCEPTED

2 Service area map Columbia River Washington Oregon Clark Providence Medicare Extra (HMO) Providence Medicare Extra + RX (HMO) Providence Medicare Choice (HMO-POS) Providence Medicare Choice + RX (HMO-POS) Providence Medicare Prime + RX (HMO-POS) Additional in-network providers may be available

3 Providence Medicare Advantage Plans Providence Medicare Extra (HMO) In -plan In -plan Providence Medicare Providence Medicare Choice (HMO-POS) Prime (HMO-POS) Monthly premium without prescription drug coverage 1 $108 $44 N/A Monthly premium with prescription drug coverage 1 $147 $77 $0 Benefits Fitness center membership Out-of-pocket maximum $2,500 $3,000 Out -of- network In -plan No deductible No deductible $195 deductible You pay You pay You pay Included with all plans at no additional cost. $3,900 combined $6,700 Out -of- network $6,700 combined Doctor office $15 $20 $30 $35 $50 Preventive care $0 $0 20% $0 30% Specialist visit $20 $30 $40 no referral $40 $50 $75 no referral Lab $0 $0 20% 20% 30% X-ray 15% 20% 20% 20% 30% Durable medical equipment 20% 20% 20% 20% 30% Diabetic supplies $0 $0 20% $0 30% Outpatient surgery $150 $250 20% $270 30% Inpatient hospital Skilled nursing facility Days 1-7: $200 Days 8 & beyond: $0 Days 1-20: $0 Days : $150/day Days 1-7: $250 Days 8 & beyond: $0 Days 1-20: $0 Days : $150/day 20% 20% Days 1-7: $270 Days 8 & beyond: $0 Days 1-20: $0 Days : $130/day Home health $0 15% 20% $0 30% Mental health and chemical dependency counseling $20 $30 20% $40 30% Therapy: PT, OT, ST $20 $30 20% $40 30% Medical eye exam $20 $30 $40 $35 $45 Routine eye exam (through VSP providers) Vision hardware allowance (through VSP providers) $15 $20 $100 every two years $100 every two years $20 Covered up to $45 $100 every two years No coverage No coverage $75 30% 30% No coverage No coverage Worldwide coverage Urgent care* $20 $30 $30 $50 $50 Emergency room* $65 $65 $65 $65 $65 Ambulance (air/ground) $100 one way $150 one way $150 one way *Diagnostic testing copayment may apply. For office visits, other charges may apply. Copayment is waived if admitted within 24 hours for the same condition. $300 one way $300 one way

4 Part D How it works Deductible Initial coverage Phase 1 Coverage gap Phase 2 Catastrophic coverage Phase 3 $80 for Providence Medicare Prime + RX (HMO-POS) only When the total paid by you and the plan reaches $2,960, Phase 2 begins. You pay only 45% of the costs of brand name drugs and 65% of the costs of generic drugs. You stay in this stage until your out-ofpocket costs reach $4,700. After that Phase 3 begins. You pay whichever of these is larger: either 5% coinsurance for the cost of the drug or $2.65 copay for generic drugs, $6.60 copay for brand name or specialty drugs. What you pay in Phase 1 Providence Medicare Extra + RX (HMO) Providence Medicare Choice + RX (HMO-POS) Providence Medicare Prime + RX (HMO-POS) Drug Tier 1-Preferred 2- Non-Preferred 3- Preferred 4- Non-Preferred 5- Injectable Meds Preferred $4 $10 $12 $20 $45 $95 33% Drug Tier 1-Preferred 2- Non-Preferred 3- Preferred 4- Non-Preferred 5- Injectable Meds Preferred $4 $10 $12 $20 $45 $95 30% 6- Specialty Meds 33% 6- Specialty Meds 30% To learn more: 1. Call us at or (TTY: 711) Service is available between 8 a.m. and 8 p.m. Monday through Friday (Pacific time). Oct.1 - Feb. 14, service is available between 8 a.m. and 8 p.m. seven days a week (Pacific time). 2. Visit us online at 3. Attend a free community meeting. 2 1 You must continue to pay your Medicare Part B Premium. 2 A Sales person will be present with information and applications. For accommodation of persons with special needs at sales meetings call or (TTY: 711). The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/ co-insurance may change on January 1 of each year.

5 Optional dental coverage Dental Benefit Features Basic option $37.50/month Enhanced option $48.20/month PROVIDENCE MEDICARE ADVANTAGE PLANS Office Visit Copay Deductible 1 Annual Maximum Waiting Periods Out-of-network Reimbursement Provider Class I. Diagnostic & Preventive Services $50 $1,500 Maximum allowable charge Any dentist 2 In and out-of-network member responsibility $50 $1,500 Maximum allowable charge Any dentist 2 In and out-of-network member responsibility Oral Examinations 20% 0% Bitewing X-rays 20% 0% Full and Panoramic X-rays 20% 0% Semiannual Teeth Cleanings 20% 0% Sealants 20% 0% Class II. Basic Services Fillings (Silver) Fillings (Composite) Class III. Major Restorative Services Crowns & Bridges 3 Dentures Extractions, Erupted Tooth n/a Oral Surgery certain n/a minor surgery Endodontics (Root Canals) Periodontics n/a 1 Deductibles are waived for Diagnostic and Preventive Services (Class 1) 2 Using a network dentist will result in significant out-of-pocket savings. 3 Crown/Bridge max: $100 per tooth per year for BASIC and $500 annual maximum for ENHANCED

6 OUR MISSION As people of Providence, we reveal God s love for all, especially the poor and vulnerable, through our compassionate service. OUR CORE VALUES Respect, Compassion, Justice, Excellence, Stewardship Providence Medicare Advantage Plans Sales Team P.O. Box 5548 Portland, OR or ; TTY: 711 Service is available between 8 a.m. and 8 p.m. Monday through Friday (Pacific time) Providence Health Plan. All rights reserved. Providence Health & Services, a not-for-profit health system, is an equal-opportunity organization in the provision of health care services and employment opportunities. <<Recycling statement goes here>> MDC-254_OR _HP_LK_W-OR_CC_WA

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